How Dr. Alzheimer Discovered a Disease in a Mental Asylum

Rod Tanchanco is a physician specializing in Internal Medicine. He writes about events and people in the history of medicine. His personal blog is at talesinmedicine.com.

Carl
didn't know what was happening to his wife. The German railway clerk
from Morfelder Landstasse and his wife Auguste had been happily
married for twenty-eight years. They had one daughter, Thekla, and
their marriage had always been harmonious; that is, until one Spring
day in 1901 when Auguste suddenly exhibited signs of jealousy.

Auguste accused
Carl of going for a walk with a female neighbor, and since then, she
had been increasingly mistrustful. Carl thought that this sudden
jealousy was unfounded. Over the next several months, Auguste's
memory began to fade. The once orderly and industrious homemaker was
making uncharacteristic mistakes in preparing home meals -- a task
that she had probably performed countless times. She wandered
aimlessly around the apartment, leaving housework unfinished. She
became convinced that a cart driver who frequented their house was
trying to harm her and that people were talking about her. Without
explanation, she began to hide various objects around the house. The
couple's neighbors sometimes discovered Auguste ringing their
doorbells for no reason.

Prior
to this change, Auguste had never been seriously ill. She was an
otherwise healthy 51-year old woman who did not drink alcohol nor
suffered from any mental illness. By November of 1901, Carl was at
wit’s end. He had no choice but to take his wife to the local
mental asylum. The physician's admittance note described her as
suffering from a weak memory, persecution mania, sleeplessness, and
restlessness that rendered her unable to perform physical or mental
work.

The
following day, the senior physician at the Asylum for the Insane and
Epileptic in Frankfurt am Main came across Auguste's clinical notes.
The unusual case seemed to stick out and the psychiatrist sensed that
there was something special about Auguste. It was the case that he
was waiting for. Dr. Alois Alzheimer decided that he should see
Auguste for himself.

Over
the next several months, Dr. Alzheimer interviewed and examined
Auguste, whose condition continued to deteriorate. He asked her to
name common objects, perform simple arithmetic, tell him where she
lived, what year it was, the color of snow, the sky, grass, and so
on. Alzheimer maintained a detailed record and even arranged for
Auguste to be photographed. One photo reveals a woman with a deeply
furrowed forehead and heavy bags under her eyes. She was wearing a
white hospital gown and her face had a tired, blank expression, with
perhaps a hint of fear. Her hands were draped over her raised knees,
with the long fingers securely interlocked.

What
struck Dr. Alzheimer was Auguste's relatively young age. He had seen
cases of mental deterioration in much older patients and had
theorized that age-related thickening of the brain’s blood vessels
led to brain atrophy. It was unusual, however, to see the condition
in a person who was only fifty-one years old. Dr. Alzheimer had only
encountered one other case similar to Auguste's. The autopsy findings
on that patient revealed shrinkage in specific brain cells but no
significant blood vessel thickening.

Dr.
Alzheimer continued his daily visits and long conversations with
Auguste. There was no cure, of course, and the limited treatments
included the use of sedatives and warm baths. At times, Auguste had
to be placed in isolation after she groped faces and struck other
patients in the clinic. She wandered aimlessly, sometimes screamed
for hours, and became increasingly hostile. By February of 1902, her
condition had advanced to the point that long conversations and
physical examinations became impossible.

On
April 8, 1906, after nearly five years of progressive mental and
physical decline, Auguste died. The official cause of death was blood
poisoning due to bedsores. Dr. Alzheimer suspected that behind her
mental illness was a strange disease, and that perhaps examining her
brain would offer some clues. When he examined the brain sections
under the microscope, his suspicion was confirmed. Dr. Alzheimer
described changes in the neurofibrils - the protein filaments found
in brain cells. He also saw peculiar deposits that he referred to a
“millet seed-sized lesions.” These pathologic findings - now
known as neurofibrillary tangles and amyloid deposits - characterize
the brains of Alzheimer's Disease patients.

Dr.
Alzheimer's discovery was not immediately well received. In fact, the
first time he presented Auguste's case and autopsy findings during a
German Psychiatry conference in 1906, the reception from the audience
was rather cold. This was the time when psychoanalysis and the
Freudian views on the relationship between childhood trauma and
mental illness were, in today's parlance, the “trending” topics
in psychiatry. Correlating mental or neurologic disorders with
histopathologic findings was not yet firmly established nor accepted.
Ninety years later, in 1998, researchers re-examined Auguste's
original brain sections and confirmed the presence of neurofibrillary
tangles and amyloid plaques.

Emil
Kraepelin, one of the most prominent psychiatrists in the early
1900s, first mentioned the term ‘Alzheimer’s Disease’ in the
1910 edition of his textbook on psychiatry. The disease was of course
still poorly understood, but one of the most famous medical eponyms
was born.

Today,
there are an estimated five million Americans diagnosed with
Alzheimer's Disease. The number is expected to rise as the population
ages. There is no cure, and the burden on the afflicted as well as
caregivers remains tremendous. The economic burden is also
substantial, with healthcare costs for dementia in general estimated
to be over $200 billion dollars in 2010. Researchers are on a quest
to find effective treatment in areas that include stem cell and gene
therapy.

References

Maurer
K. Alzheimer :
the life of a physician and the career of a disease.
New York: Columbia University Press; 2003.